Material and Method: Between 2001 and 2019 we evaluated 26 patients who were performed total knee arthroplasty with a history of previous high tibial ostetomy. This group was compared with 26 patients with similar age, body mass index (BMI), follow-up time and prosthesis design from remain primary total knee arthroplasty (p-TKA). All patients were evaluated clinically according to range of motion (ROM), Knee Society Score (KSS), Knee Society Score-Function (KSSF), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), preoperatively and postoperatively. Radiologic assesments were evaluated pre- and postoperatively by antero-posterior and lateral X-ray view, and orthoroentgenogram. Femorotibial angle (FTA), tibial slop and Insall-Salvati ratio were compared in both groups.

Results: In HTO group all 26 patients were female (100%) while in p-TKA group there were 19 female (73.1%)and 7 male (26.9%) patients. The mean age was similar (HTO = 65,7; p-TKA=65,2). Total follow-up time was 52 months in HTO group; 55 months in p-TKA group. The mean time interval between HTO and TKA was 125 ± 22 (45-192) months. There were no significant difference between the groups regarding preoperative demographic or clinical data.

Conclusion: The main finding of this study was that, both primary TKA and TKA after HTO had similar clinical and radiological results.

There are numerous studies with varying results. Some authors reported similar results with primary TKA ^5-7 while some reported counterview ^8,9 due to possible technical diffuculties like shortening of the patellar tendon and transposition of tibial condyle.

Also soft tissue scarring due to previous operation and diffuculty in the exposure may give additional risk especially to the tibial tubercle avulsion ¹⁰.

The purpose of this study is to compare the clinical and radiological results between primary TKA and TKA after HTO. Our hypothesis was in both groups there would be similar results.

All patients were evaluated clinically according to range of motion (ROM), Knee Society Score (KSS), Knee Society Score-Function (KSSF), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), preoperatively and postoperatively.

Radiologic assesments were evaluated pre- and postoperatively by antero-posterior and lateral X-ray view, and ortoroentgenogram. All radiological measurements were performed by two trained orthopaedic fellows. Femorotibial angle (FTA), tibial slop and Insall-Salvati ratio were compared in both groups.

All HTO operations were made using opening wedge technique with medial longutidinal incision.

Patients with HTO who had persistent pain at least 6 months that were resistant to conservative treatment and severe osteoarthritis in their plain radiographs revised with TKA (Genesis 2, Smith&Nephew, Menphis, TN, USA). Midline longuditinal skin incision were used in all patients. In HTO group the insicion was extended due to hardware removal before arthroplasty procedure. Posterior cruciate retaining (CR) or sacrifiying (PS) femoral component was used according to perioperative flexion contracture and posterior cruciate ligament stability.

Postoperative rehabilitation was the same in both groups. On the first postoperative day passive knee ROM exercises started with continous passive motion (CPM) machine. Weight bearing is allowed with two crutches as patient tolerated.

The study was approved by Institutional Review Board (2021/02-23) and informed consent was obtained from each patient.

Statistical Analysis
The statistical analyses were performed using SPSS, version 22 (IBM SPSS Statistics for Windows, Armonk, NY; IBM Corp., Released 2013). First, a Kol-mogorov-Smirnov test was used to determine which variables should be included in the data analysis and whether the data for the variables were normally distributed. Student T-test was used for normally distributed, and Mann-Whitney U test for non-normally distributed variables.

The Mann-Whitney U test was used to compare continuous variables across the groups. The mean ± standard deviation, median (Q1 (1st quartile)-Q3 (3rd quartile)), frequency and percentage were reported as descriptive statistics (p <0.05). Power analysis was not performed as all cases were included.

There were no significant difference between the groups regarding preoperative demographic or clinical data. Also no significant difference was found regar-ding KSS, KSS- f, WOMAC (Table 1).

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Table 1: HTO: high tibial osteotomy, p-TKA: primary total knee arthroplasty, KSS: Knee Society Score, KSS-F: Knee Society Score-Function, WOMAC: The Western Ontario and McMaster Universities Osteoarthritis Index, Preop flex.: Preoperative flexion angle, Postop flex.: Postoperative flexion angle, Postop ext.def.: Postoperative extension deficit angle.

Only postoperative flexion angle was found to be significant which is better in p-TKA group. Between radiologic data only preoperative tibial slope is higher in HTO group which is expected (Table 2).

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Table 2: HTO: High Tibial Osteotomy; p-TKA: Primary Total Knee Arthroplasty; FTA: Femoro-Tibial angle.

Only one revision due to deep joint infection was performed in HTO group and two staged revision was performed, while there was none in p-TKA group.

In 14 of the HTO group and 8 of the p-TKA group PS design prosthesis was used. We found no correlation between CR and PS design according to clinical and radiologic parameters.

HTO is a good option especially for young active medial compartman osteoarthritis. Even though mid to long term results are good in literature ^1, there may be a need for a revision to arthroplasty in 30% of the patients ¹¹.

There are some opposite views in the literature regarding the results of TKA after failed high tibial osteotomy. Haslam and Erak (8, 9) reported poorer outcomes after HTO. While Ramappa and friends ¹² found no difference in complications, revisions and functional outcomes. Our study reveals that TKA after HTO had similar results compared to primary TKA.

The main concerns about TKA after HTO is patellar length and tibial tubercle position and tibial slope. Nha and colleaques ¹³ evaluated the posterior tibial slope in their meta analysis and found that open wedge HTO increases the slope. Theoretically increased posterior slope may weakened posterior cruciate ligament ¹⁴. In our study PS design prosthesis was used more in HTO group (which is more than half of the cases) as expected. Also our posterior slope angles were higher in HTO group. But we did not find any correlation between increased slope and clinical scores.

In HTO group we found lower insall-salvati ratios (patella baja) which is significantly important. Kazakos et al ¹⁵ found similiar results in their study.This may cause anterior knee pain and increase in revision rates.

However we could not match this finding with our overall clinical findings.

We prefer open wedge technique in correcting varus malalignment. Some authors compare open wedge and closing wedge technique regarding the results of TKA. Badawy and Bastos ^16,17 found similar results in both technique.

An important finding in our sudy was postoperative flexion differences. Even though it was not changed the overall clinical scores in primary TKA group flexion angles were better. There may be some reasons to explain it. First of all preoperative flexion angles were lower than p-TKA group which may be related with previous surgery. As known most predictor of the postoperative flexion angle is preoperative degree ¹⁸. To balance soft tissues is more diffucult in osteotomised patients which is also the other possible factor for decreased flexion ¹⁹.

Postoperative infection is another possible complication in osteotomised group. Due to higher operation time, soft tisse scarring, implant removal some authors reported increased infection rates²⁰ . In the review of Chen ²¹ and friends infection rates was found to be 1.4%. In our HTO group only 1 patient (3.8%) revised due to infection where there is none in primary TKA group. Due to small sample size it is diffucult to make an inference.

This study has several limitations. Besides being retrospective design sample sizes are small. We try to match two groups as close as possible regarding age, BMI, follow up time, prosthesis design. All operations were done by a single senior surgeon. But still we could not eliminate all of the selection bias.

In conclusion as in our hypothesis total knee arthroplasty after previous high tibial osteotomy has satisfactory results. Overall functional scores, patient satisfaction and pain relief are similar with primary knee arthroplasties. High tibial osteotomy is a good option in active young patients with medial compartment osteoarthritis, although some of them need to be revised after a while.

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